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Admisson Form

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Admisson Form

Admission Form | A Different World

Welcome to the admission process at A Different World Services. To ensure we provide the best support tailored to each individual, we kindly ask you to complete the following admission form. This comprehensive form is essential for assessing and addressing the specific needs of each participant prior to enrollment in our programs.
Please take your time to provide all the necessary information. If you need assistance while filling out the form, our team is here to help.

Note: If you need to continue filling out the form later, simply click the "Save and Resume Later" button to save your progress.

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- Step 1 of 12

of the Pregnancy

Date of Initial Contact

Date of Assessment

Relationship to applicant of person referring applicant *

Legal authorized representative
Individual
Other

Email *

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Name of Individual (Last, First): *

Gender *

Date of Birth

SSN

Medicaid

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Address *

Address Line 1

City

State

Zip Code

Phone

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Select the service you are interested in: *

Sources of Information (family, friends, therapist, medical records, school staff, etc.):

Family Member
Therapist; (name and agency)
School records or staff (name and school)
Medical records (specify physician and date of record)
Psychosocial/CBHA/Assessment: (specify type of document and agency)
Others

Name and Agency

Specify Physician and Date of Record

Name and School

Specify Type of Document and Agency

Other Details

Reason why the individual is requesting services: *

Current place of residence: *

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List of services client currently receiving and describe effectiveness:

Individual/Family/Group Therapy (specify type and name of therapist)
Mentor (name and phone#)
Certified Behavioral Analyst (contact info)
Psychiatric Services (specify name, agency, phone#)

Specify Type and Name of Therapist

Certifield Behavioral Analyst Contact Info

Mentor Name and Phone

Psychiatric - Specify Name, Agency and Phone

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Mental/Developmental Status

⦁ Does the client have any of the following diagnosis:

Mental Disorder *

Developmental Disability *

Physical Disabilities *

Your answer is yes, please describe.

The Condition:

Does the client use prescription medications? If yes please list:

The severity of the disorder or disability:

Does the client use any non-prescription medications? If yes please list:

Any current or previous treatment:

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Does the client have any of the following?

Asthma *

Epilepsy *

Allergies *

Diabetes *

Eating Disorders *

Visual Impairment *

Physical impairment *

Infection Disease *

Special Diet *

Pregnancy *

Chronic Medical Condition *

Incontinence *

Type and severity of the condition:

The treatment the client is receiving for the condition:

Name and dosages of the medication the client receives:

Does the client need assistance with eating, dressing, bathing, grooming or toileting? *

Does the client have any special treatment or specific therapies needed as a result of any medical conditions? *

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BEHAVIORS

Does the client have a history of any of the following?

Physical assaultiveness *

Cruelty to others *

Violence to self or others *

Verbal assaultiveness *

Attempt to poison others *

Stealing *

Sexual assaultiveness *

Use of weapons *

If the answer to any of the above question is yes, please describe:

The behaviors:

The frequency and duration of the behaviors:

The approximate date of the last occurrence of behaviors:

Is there anything that seems to trigger the behavior:

Strategies to deal with the behavior:

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Does the individual have a history of any of the following?.

Depression or withdrawal *

Suicide attempts *

Restlessness or hyperactivity *

Anxiety *

Paranoia *

Inappropriate sexual activity *

Mood Swings *

Hallucination *

Non-compliance *

Suicide ideation *

If the answer to any of the above question is yes, please describe:

The approximate date of the last occurrence of behaviors:

The behaviors:

Is there anything that seems to trigger the behavior:

The frequency and duration of the behaviors:

Strategies to deal with the behavior:

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Does the individual have a history with any of the following?

Disruptiveness *

Ingestion of toxic substances *

Refusal of Medications *

Tantrums *

Substance Abuse *

Refusal of Medical treatment *

Wandering *

Resistance to authority figures *

Refusal to bathe or wear clean clothes *

AWOL *

If the answer to any of the above question is yes, please describe:

The approximate date of the last occurrence of behaviors:

The behaviors:

Is there anything that seems to trigger the behavior:

The frequency and duration of the behaviors:

Strategies to deal with the behavior:

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Does the individual have any mental/physical disabilities that would interfere with his/her ability to evacuate the facility in the event of an emergency? If so please explain:

Does the individual have any specific personal needs for assistance with instrumental activities of daily living? (Ex: help getting out of bed, help walking, eating, brushing teeth etc.) If yes please explain:

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Disposition

Applicant accepted into program *

Yes
No
Decision Pending

If no, was client referred to other services, put on waiting list, or referred for further assessment?

Please attach a referral form into this screening form if the client was not admitted to the program and referrals for other programs and/or other services were made.

Applicant or Authorized Representative Signature

Clear Signature

Date

Upload Supporting Documents (Max 10)

Click or drag files to this area to upload.You can upload up to 10 files.

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Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

A Different World Services is dedicated to empowering individuals with intellectual and developmental disabilities through personalized care, community involvement, and skill-building programs.

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(+1) 804-398-3955

Admisson Form

Admission Form | A Different World

Note: If you need to continue filling out the form later, simply click the "Save and Resume Later" button to save your progress.

Mental/Developmental Status

Your answer is yes, please describe.

Does the client have any of the following?

BEHAVIORS

Does the individual have a history of any of the following?.

Does the individual have a history with any of the following?

Disposition

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